A clubfoot, or congenital talipes equinovarus (CTEV),[1] is a congenital deformity involving one foot or both.[2] The affected foot appears rotated internally at the ankle. TEV is classified into 2 groups: Postural TEV or Structural TEV. Without treatment, persons afflicted often appear to walk on their ankles, or on the sides of their feet. It is a common birth defect, occurring in about one in every 1,000 live births. Approximately 50% of cases of clubfoot are bilateral. In most cases it is an isolated dysmelia. This occurs in males more often than in females by a ratio of 2:1.

Contents

[hide] 1 Deformities 2 Causes

3 Treatment

o 3.1 Non-surgical treatment and the Ponseti Method

o 3.2 Surgical treatment

4 Famous people

5 In literature

6 References

7 External links

[edit] Deformities

The deformities affecting joints of the foot occur at three joints of the foot to varying degrees. They are [2]

Inversion at subtalar joint Adduction at talonavicular joint and

Equinus at ankle joint

The deformities can be remembered using the mnemonic, "InAdEquate" for Inversion, Adduction and Equinus.[2]

[edit] Causes

There are different causes for clubfoot depending on what classification it is given. Structural TEV is caused by genetic factors such as Edwards syndrome, a genetic defect with three copies of chromosome 18. Growth arrests at roughly 9 weeks and compartment syndrome of the affected limb are also causes of Structural TEV. Genetic influences increase dramatically with family history. It was previously assumed that postural TEV could be caused by external

influences in the final trimester such as intrauterine compression from oligohydramnios or from amniotic band syndrome. However, this is countered by findings that TEV does not occur more frequently than usual when the intrauterine space is restricted.[3] Breech presentation is also another known cause.[citation needed] TEV occurs with some frequency in Ehlers Danlos Syndrome and some other connective tissue disorders. TEV may be associated with other birth defects such as spina bifida cystica.

[edit] Treatment

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Clubfoot is treated with manipulation by podiatrists, physiotherapists, orthopedic surgeons, specialist Ponseti nurses, or orthotists by providing braces to hold the feet in orthodox positions, serial casting, or splints called knee ankle foot orthoses (KAFO). Other orthotic options include Dennis-Brown bars with straight last boots, ankle foot orthoses and/or custom foot orthoses (CFO). In North America, manipulation is followed by serial casting, most often by the Ponseti Method. Foot manipulations usually begin within two weeks of birth. Even with successful treatment, when only one side is affected, that foot may be smaller than the other, and often that calf, as well.

Extensive surgery of the soft tissue or bone is not usually necessary to treat clubfoot; however, there are two minimal surgeries that may be required:

1. Tenotomy (needed in 80% of cases) is a release (clipping) of the Achilles tendon - minor surgery- local anesthesia

2. Anterior Tibial Tendon Transfer (needed in 20% of cases) - where the tendon is moved from the first ray (toe) to the third ray in order to release the inward traction on the foot.

Of course, each case is different, but in most cases extensive surgery is not needed to treat clubfoot. Extensive surgery may lead to scar tissue developing inside the child's foot. The scarring may result in functional, growth and aesthetic problems in the foot because the scarred tissue will interfere with the normal development of the appendage. A child who has extensive surgery may require on average two additional surgeries to correct the issues presented above.

In stretching and casting therapy the doctor changes the cast multiple times over a few weeks, gradually stretching tendons until the foot is in the correct position of external rotation. The heel cord is released (percutaneous tenotomy) and another cast is put on, which is removed after three weeks. To avoid relapse a corrective brace is worn for a gradually reducing time until it is only at night up to four years of age.

[edit] Non-surgical treatment and the Ponseti Method

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Main article: Ponseti Method

Treatment for clubfoot should begin almost immediately to have the best chance for a successful outcome without the need for surgery. Over the past 10 to 15 years, more and more success has been achieved in correcting clubfeet without the need for surgery. The clubfoot treatment method that is becoming the standard in the U.S. and worldwide is known as the Ponseti Method [4]. Foot manipulations differ subtly from the Kite casting method which prevailed during the late 20th century. Although described by Dr. Ignacio Ponseti in the 1950s, it did not reach a wider audience until it was re-popularized around 2000 by Dr. John Herzenberg in the USA and in Europe and Africa by NHS surgeon Steve Mannion while working in Africa. Parents of children with clubfeet using the Internet [5] also helped the Ponseti gain wider attention. The Ponseti method, if correctly done, is successful in >95% of cases [6] in correcting clubfeet using non- or minimal-surgical techniques. Typical clubfoot cases usually require 5 casts over 4 weeks. Atypical clubfeet and complex clubfeet may require a larger number of casts. Approximately 80% of infants require an Achilles tenotomy (microscopic incision in the tendon requiring only local anesthetic and no stitches) performed in a clinic toward the end of the serial casting.

After correction has been achieved, maintenance of correction may require the full-time (23 hours per day) use of a splint—also known as a foot abduction brace (FAB)—on both feet, regardless or whether the TEV is on one side or both, for several weeks after treatment. Part-time use of a brace (generally at night, usually 12 hours per day) is frequently prescribed for up to 4 years. Without the parents' participation, the clubfoot will almost certainly recur, because the muscles around the foot can pull it back into the abnormal position. Approximately 20% of infants successfully treated with the Ponseti casting method may require a surgical tendon transfer after two years of age. While this requires a general anesthetic, it is a relatively minor surgery that corrects a persistent muscle imbalance while avoiding disturbance to the joints of the foot.

The developer of the Ponseti Method, Dr Ignacio Ponseti, was still treating children with clubfeet (including complex/atypical clubfeet and failed treatment clubfeet) at the University of Iowa Hospitals and Clinics well into his 90s. He was assisted by Dr Jose Morcuende, president of the Ponseti International Association.

The long-term outlook [7] for children who experienced the Ponseti Method treatment is comparable to that of non-affected children.

Watch a Video on the Ponseti Method

Botox is also being used as an alternative to surgery. Botox is the trade name for Botulinum Toxin type A. a chemical that acts on the nerves that control the muscle. It causes some paralysis(weakening) of the muscle by preventing muscle contractions (tightening). As part of the treatment for clubfoot, Botox is injected into the child’s calf muscle. In about 1 week the

Botox weakens the Achilles tendon. This allows the foot to be turned into a normal position, over a period of 4–6 weeks, without surgery.

The weakness from a Botox injection usually lasts from 3–6 months. (Unlike surgery it has no lasting effect). Most club feet can be corrected with just one Botox injection. It is possible to do another if it is needed. There is no scar or lasting damage. BC Women and Childrens Hospital

[edit] Surgical treatment

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On occasion, stretching, casting and bracing are not enough to correct a baby's clubfoot. Surgery may be needed to adjust the tendons, ligaments and joints in the foot/ankle. Usually done at 9 to 12 months of age, surgery usually corrects all clubfoot deformities at the same time. After surgery, a cast holds the clubfoot still while it heals. It is still possible for the muscles in the child's foot to try to return to the clubfoot position, and special shoes or braces will likely be used for up to a year or more after surgery. Surgery will likely result in a stiffer foot than nonsurgical treatment, particularly over time.

Without any treatment, a child's clubfoot will result in severe functional disability, however with treatment, the child should have a nearly normal foot. He or she can run and play without pain and wear normal shoes. The corrected clubfoot will still not be perfect, however; a clubfoot usually stays 1 to 1 1/2 sizes smaller and somewhat less mobile than a normal foot. The calf muscles in a leg with a clubfoot will also stay smaller.

[edit] Famous people

The club-foot, by José de Ribera.

Many notable people have been born with clubfoot, including the Roman emperor Claudius, Egyptian pharaoh Tutankhamun, statesman Prince Talleyrand, Civil War politician Thaddeus Stevens, the comedian Damon Wayans, actors Gary Burghoff, Dudley Moore and Eric The Midget from The Howard Stern Show, footballer Steven Gerrard, sledge hockey player Matt Lloyd (Paralympian),mathematician Ben Greenberg, and filmmaker Jennifer Lynch (daughter of David Lynch).

British Romantic poet Lord Byron had a clubfoot, which caused him much humiliation.

Actor/musician/comedian Dudley Moore was born with a club foot. This was mostly unknown to the public as he wore one shoe with a slightly bigger sole to compensate when walking.

Kristi Yamaguchi was born with a clubfoot, and went on to win figure skating gold in 1992. Soccer star Mia Hamm was born with the condition. Baseball pitcher Larry Sherry was born with club feet, as was pitcher Jim Mecir, and both enjoyed long and successful careers. In fact, it was suggested in the book Moneyball that Mecir's club foot contributed to his success on the mound—it caused him to adopt a strange delivery that "put an especially violent spin" on his screwball, his specialty pitch. San Francisco Giants (the team with the all-time most clubbed feet players) infielder Freddy Sanchez cites his ability to overcome the defect as a reason for his success.[8] Tom Dempsey of the New Orleans Saints, born with a right club foot and no toes (this was his kicking foot), kicked an NFL record 63 yard field goal. This kick is famous as the longest regular-season NFL kick in history(until 2009).

Nazi Propaganda Minister Joseph Goebbels had a right clubfoot (possibly incurred after birth as a complication of osteomyelitis),[9] a fact hidden from the German public by censorship. Because of this malformation, Goebbels needed to wear a leg brace. That, plus his short stature, led to his rejection for military service in World War I.

De Witt Clinton Fort was born with a clubfoot. De Witt Clinton Fort was known during the American Civil War as Captain "Clubfoot" Fort, C.S.A..

Tutankhamun suffered from a club foot and a cleft palate and it is likely that he needed a cane to walk

Definition

Club foot repair, also known as foot tendon release or club foot release, is the surgical repair of a birth defect of the foot and ankle called club foot.

Purpose

Club foot or talipes equinovarus is the most common birth defect of the lower extremity, characterized by the foot turning both downward and inward. The defect can range from mild to severe and the purpose of club foot repair is to provide the child with a functional foot that looks as normal as possible and that is painless, plantigrade, and flexible. Plantigrade means that the child is able to stand with the sole of the foot on the ground, and not on his heels or the outside of his foot.

Demographics

In the United States, club foot is a common birth defect, and occurs at a rate of one to four cases per 1,000 live births among whites. Severe forms of clubfoot affect some 5,000 babies (about one in 735) born in the United States each year. Boys are affected with severe forms of clubfoot twice as often as girls. The risk increases 30-fold in individuals who have a relative of the first-degree affected by the defects.

Description

A newborn baby's club foot is first treated with applying a cast because the tendons, ligaments, and bones are quite flexible and easy to reposition. The procedure involves stretching the foot into a more normal position and using a cast to maintain the corrected position. The cast is removed every week or two, so as to stretch the foot gradually into a correct position. Serial casting goes on for approximately three months.

In 30% of cases, manipulation and casting is successful, and the foot can be placed in a brace to maintain the correction. In about 70% of cases, manipulation and castings alone do not correct the deformity completely and a decision will be made concerning surgery.

The type of surgery depends on how severe the club foot is. The deformity features tight and short tendons around the foot and ankle. Surgery consists of releasing all the tight tendons and ligaments in the posterior (back) and medial (inside) aspects of the foot and repairing them in a lengthened position. Metal pins may also be used to maintain the bones in place for some six weeks. Surgery usually involves an overnight stay in hospital. After surgery, the foot is casted for some three months, followed by the use of a brace to hold the correction. The brace is worn for approximately six to 12 months after surgery.

Diagnosis/Preparation

Presurgical diagnosis requires radiography. The evaluation usually includes only the acquisition of weight-bearing images because the stress involved is reproducible. In babies, weight-bearing is simulated by the application of dorsal flexion stress.

Some surgeons prefer to wait until the child is about one year old before performing surgery, so that the foot may grow a little larger to facilitate surgery. Other surgeons operate as early as three months of age when it becomes clear that further castings will not achieve any more correction.

Aftercare

The patient usually stays in the hospital for two days after club foot repair. The foot is casted and kept elevated, with application of ice packs to reduce swelling and pain. Painkillers may also be prescribed to relieve pain. During the 48 hours following surgery, the skin near the cast and the toes are examined carefully to ensure that blood circulation, movement, and feeling are maintained. After leaving the hospital, the cast is usually left on for about three months. Skin irritations due to the cast or infections may occur. A course of physical therapy may be indicated after removal of the cast to help keep the foot in good position and improve its flexibility and to strengthen the muscles in the repaired foot. The well-treated clubfoot is no handicap and is fully compatible with a normal, active life. Most children who have undergone club foot repair develop normally and participate fully in any athletic or recreational activity that they choose.

Risks

The risks involved in club foot repair are the general risks associated with anesthesia and surgery.

Risks Associated With Anesthesia

adverse reactions to medications breathing problems

Risks Associated With Surgery

excessive bleeding infections

Normal Results

If club foot repair is required, the foot usually becomes quite functional after surgery. In some cases, the foot and calf may remain smaller throughout the patient's life.

Morbidity and Mortality Rates

If left untreated, club foot will result in an abnormal gait, and further deformity may occur on side of the foot due to preferential weight bearing.

Alternatives

The Ponseti Non-Surgical Treatment

Dr. Ignacio Ponseti developed this method which consists of a weekly series of gentle manipulations followed by the application of casts which are placed from the toes to the upper thigh. Five to seven casts are applied every week. Before applying the last cast, which is worn for three weeks, the heel-cord is cut to finalize the correction of the foot. By the time the cast is removed the heel-cord has healed. After this two-month period of casting, a splint is worn full-time by the patient for a few months and is then worn only at night for two to four years. Special shoes also maintain the foot in the corrected position.

The French Treatment

This method consists of daily physical therapy, featuring gentle and painless stretching of the foot. The foot is then taped to maintain the corrected position until just the next day's visit. At night, the taped foot is inserted into a continuous passive motion machine at home to maximize the amount of stretching. The tape is removed for a few hours each day to wash the foot, air the skin, and to perform exercises. Removable splints are also used to support the taped foot. The one-hour physical therapy sessions are conducted five days each week for approximately three months. Taping is stopped when the child starts walking.

Resources

Books

Lehman, W. B. The Clubfoot. Philadelphia: Lippincott, Williams and Wilikins, 1980.

Ponseti, I. V. Congenital Clubfoot. Fundamentals of Treatment. Oxford: Oxford University Press, 1996.

Simons, G. W. The Clubfoot: The Present and a View of the Future New York: Springer Verlag, 1994.

Deformations:In utero, the feet can be pressed into odd postures. The key thing about such deformation by outer pressure is that the feet themselves are passive in the process.

They would not be that way of their own growth programming. Once straightened out by their own resilience or with a helping

nudgeor two (exercises, casts, or shaped shoes etc.), such feet will do fine. They maintain correction naturally, as correct form is already inherent in the tissue blue print.

 There are a variety of conservative "corrections". They share a common property, they are gentle forces applied to the foot in the direction of return of shape. A hands-on manipulation is an externally applied force.

A corrective shoe is an externally applied force. A cast is an externally applied force. The big difference is how long applied and how meticulously shaped. Frankly, many orthopedists cringe at the "exercises" that parents do to their own children in the quest to avoid "braces" (the little white shoe with the thingy on the bottom). "Exercise" sounds like a nice upbeat word, but it is not rare to see feet literally dislocated by inexpert hands.

Club Foot:Club foot is not just a bent foot. If you straighten a club foot and then let it alone it goes back to being clubbed. That is the one single most important fact about club foot from which nearly every decision can be properly deduced. Club feet work from a bent blue print. They seek club-ness with growth. Correction of shape must

not be merely attained. It must be actively maintained. To not maintain a corrected club foot is to play Russian Roulette with half the chambers loaded.

Attaining correction of club foot deformity was anything but easy even as recently as the 1930's. In fact adults with uncorrected club feet sought treatment by prosthetics.

This man had the typical club foot deformity that we see in the new born, except that as an adult he has to walk on it - as there was no effective treatment for him as a child nor did a late reconstructive procedure exist for him as an adult.

Note the left (club foot) heel at the red arrow and the right normal heel at the yellow arrow. The orthotist created a raised right shoe with a laced sock to allow needed space to place a false foot below the left club foot, assisted by a bit of left hip hiking. This was life in the 20's and 30's. Even in the 50's, we saw such folks who had adjusted to this state of affairs.

But not everybody could deal with the intact look. How far will people go to look better? Far. The woman above could not bear these feet even though she walked on them well into her middle years.

How far will people go? In the old days, the options were stark,  sobering. It isn't vanity that leads to a woman seeking amputation and prosthetic substitution. That was the best way to get the best prosthesis for function and least notice from others. It wasn't about getting noticed but rather about not getting noticed. That is the essential difference between "cosmetic" and reconstructive surgery.

The single greatest problem and the fear of parents was and still is ostracism. Back then, women were apt to select ablative surgery to permit better prosthetics with less risk of ostracism. Such prosthetics were

capable of near normal levels of function (see SACH).

What else do we learn from the past? Children and adults with club feet who do not have additional impairments can walk. However, unprotected, the feet take a beating, they become sore, and the gait is unsteady.

But this was palliation, not correction. Orthopedics attacked from two directions: 1) Early manipulative techniques combined with casts and 2) More aggressive surgeries, many of which were made more effective by cast pretreatment. Various surgical strategies all had shortcommings, but the justification was better feet than doing nothing.

There were stunning successes with casts + manipulation methods but it was a percentage thing. Some were great. Some were, after concerted effort, left as if untreated. Between these extremes was the range of most outcomes.

It was clear enough, very aggressive and early (immediate) manipulation of club feet on day one of life and thereafter did best.

But, still, many very stiff feet did not yield. One noted practitioner urged frequent manipulations and very skilled cast applications - each time performed under anesthesia. Multiple aggressive manipulations and anesthesia sessions, led to many better feet, yet many failures persisted.

In recent years, this concept has been revisited with continuous passive motion machines and splinting with some success. Limited lengthening of a posterior tendon may be used to boost the process. The formula is still essentially the more movement and holding in the direction of correction the better - for some feet, more feet, but still, not all of them. Botulinum toxin has been used for paralytic versions of clubbed feet with some success. Recently a similar usage was reported from Texas Scottish Rite Childrens Hospital. It is yet another way to create suppleness in the shortened tissues.

Even in the most aggressively conservative hands, the surgical rate was about 40%. Critics also argued that even in the 60% of successes, were many "questionable" feet. It depends on the criteria. If patient satisfaction was "glad not to need amputations" then the 60% rating was solid. But if the criteria included willingness to show bare feet on a public beech, or engage in sports, then another lesser statistic emerges. It comes down to "pursuit of happiness". What does that take? Avoiding surgery? Surgery? Or just plain outcome? Throw in risk. It is fear of the latter that has parents looking for conservative choices, even if monumental in scope and unequal to surgery in outcomes. Pursuit of

happiness... but whose?

For feet that resist manipulative correction the surgical question was "Just what needs to be released to get a real, not just a partial or semicosmetic correction?"

The answer turned out to be "Everything". Club foot surgery essentially divides all the ligaments connecting the foot bones and lengthens all the tendons to allow total mobility.

With that strategy, as was championed by Dr. Turco, real corrections are now possible. With that insight an array of me-too variations touting one skin incision over another flooded the reporting. Despite the rhetoric, the modern operations stress completeness. Some surgeons remind us of rotational needs, other stress bone column geometry, but to get there you have to disconnect a lot of stiff stuff.

"Corrections", of bone position and foot shape. But growth? It is still a club foot, no? Of the feet that come to surgery (60% of them) 40% of those come to surgery again. A "corrected" club foot that is just let loose to go its own way will do exactly that. Its own way is clubbed. Some sort of maintenance foot wear is recommended in the very early years after correction. The kids are too young to mind and the potential for recurrence too

great to ignore.Nowadays we expect all club feet to look good and be functional. The one unsolved issue is the smaller size of both foot and calf. When both feet are club feet, size is not a problem. But one sided club foot may result in ½ to 2 sizes difference. There are shoe and insert tricks to deal with this. But size equalization is

not yet solved.

However, it is a big world. Strange things can walk in...

such as these feet:This 12 year old boy was walking on these club feet. Note the knobs on what is anatomically the foot top but which is his weight bearing area. He trips and hurts himself, he said.

Attempts to straighten these feet included pins through the feet and through the shins to large metal rings with turn buckle parts which were dialed out progressively, until...

until his shin bone broke, actually both tibias broke! Of course they had to be allowed to heal. He has scars (you can see one on the right ankle area) from earlier failed releases done several times. Releases & Ilazarov frames did not even slightly correct these feet. There is nothing that ALWAYS works. In this case neither side budged.

Back to prosthetics?

No.

Surgery for correction isn't all that's new. There is also "salvage" surgery.

Rather than remove the foot, we can remove internal substance to generate space and mobility to help the nastiest looking feet. These are the same feet as above. The youngster is getting about fine. The lump of thickened skin, that served as his heel, is shrinking by the week. We can still see some of that thickened skin on the outer side of the ankle above. This was done in a short single step operation. No

external metal. By hollowing out the talus the heel can be counter shaped and placed inside - easily (talo-calcaneal intussuseption). X-rays look weird but the feet look fine and work.

 

 

Valgus Foot:

These methods are not only for club foot deformity but any similar foot deformation including the opposite type called "Valgus" foot. The severe paralytic valgus foot twists out rather than in. This forefoot is twisted 90 degrees off alignment with the heel which is 90 degrees off relationship with the leg. On the right we see the correction (the white is powder after taking plaster castings).

So, what did we learn? Beware of slogans. There is easy stuff and there is difficult stuff. No one method, so & so's exercise, the wachamacallit brace, the whoozie's operation, whatever - no one method is appropriate for the full range of problems that we see.

 

Macrodactyly is a focal gigantism present at birth but progressive. Sometimes a single digit will grow to enormous size. One of our children had a toe as long and as wide as the rest of the foot. It is variable in the extent and degree of soft tissue enlargement. The latter can wedge the foot apart and thus deform the uninvolved bones.

The x-ray to the right shows a toddler's foot. The great toe is longer than the foot. The toe bones and the metatarsal (between red arrows) are very wide. Normal width is seen between the green arrows. The yellow arrow points out normal skin thickness. The blue arrows point out the excessive tissue that triples the thickness of the foot and which wedges the second toe off in the wrong direction.

As with severe club foot, many places used to and still do amputate the abnormal parts of the foot. In that case the great toe and its metatarsal would go. We prefer staged growth arrests (to stop linear growth with segment removal to aim at mature length (to grow into) with mass reduction. That includes narrowing oversized bones

by longitudinal section.  The lengthy process of staging an ultimate foot match makes some folks prefer amputation. It depends quite a bit on how much of the mid foot is involved.

This same condition may involve fingers and hands.

 

 

 

Ectromelia is a failure to form the central portion of the terminal limbs (hands &/or feet). It may be a first case by spontaneous gene mutation, however, most have an involved parent as it is a genetic disorder.

Many have no difficulty with walking at all but significant problems with shoe wear. Treatment problems are those of timing. These feet can be closed up to look fairly reasonable. However, avoiding growth arrest in the process is important. Many wait until maturity for definitive reconstruction. Interestingly, many of those who do wait find that they really are OK with it and elect to let the feet be.

Our advise is to base decision making on function. If function is a problem, examine to see what specifically is interfering with the needed processes of walking. Address those items. That may well be something other than a cosmetic attack. For example, an orthotic-prosthetic hybrid may be fabricated which extends the foot rolling point forward to where a foot should have a rolling line (metatarsal heads). Depending on how much tissue exists, the reconstructive approach might not match the prosthetic extension in ability to further walking mechanics. Each case needs individual consideration of all the issues.

There are other methods for the intermediate problems. There are other ways to deal with the relapsed club feet that are not discussed here. The particulars get too particular for those. Just know that there are many tools in the tool chest.